Healthcare Provider Details

I. General information

NPI: 1780277319
Provider Name (Legal Business Name): IVAN DANE YONCE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 02/15/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316B JAMES MADISON HWY, FORK UNION, VA 23055
FORK UNION VA
23055
US

IV. Provider business mailing address

PO BOX 187
FORK UNION VA
23055-0187
US

V. Phone/Fax

Practice location:
  • Phone: 434-842-3208
  • Fax: 434-842-1447
Mailing address:
  • Phone: 434-842-3208
  • Fax: 434-842-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202007854
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: